Supreme Court Upholds Health Care Law; APTA Reiterates Priorities

In a historic and long-awaited decision, the Supreme Court today upheld the Affordable Care Act (ACA). APTA, which has remained neutral on ACA and the subsequent Supreme Court case, announced that its current legislative and regulatory strategies will continue, and reiterated its philosophy that the nation's health care system must address several fundamental patient-centered issues: coverage, access, quality, and costs.

"APTA has for years been an advocate for a health care system that includes rehabilitation as a core benefit, demonstrates the value of physical therapy to patients, embraces innovation in reforms that are patient centered, and provides a solution to a system that for too long has been high in costs and disparate in outcomes and quality," APTA President Paul Rockar Jr, PT, DPT, MS, said in a statement. "We will continue to work with legislators, policy makers, insurers and other decision makers to ensure that these priorities are addressed in this law and future health care reforms—whether at the national or state level, or through individual private payment systems."

APTA's Government Affairs staff is currently reviewing the Supreme Court decision and will provide a more detailed analysis to members in the coming days and weeks as more information becomes available.

"We are committed to providing our leaders, members, and components with the information they need to advocate effectively for these priorities nationally and at the state level," added Rockar.

Comments

this is another amazing departure from the principles of the American Revolution, it which individual liberty was the guiding light: freedom from tyranny of the church and state combined. That the state -meaning the federal government- has the power above the states to enforce mandatory health payments, in effect a tax, to redistribute wealth goes against the pioneer principles of our nation's founding fathers. I agree reform is needed, but not a cadillac program requiring that all pay into a system, is clearly a wealth redistributing system; government likes to mandate programs, then chronically underfunds them; nothing could be more threatening to our democracy at such a time as this when European banks are threatened with bankruptcy, governments of Western nations are over spending/ "stimulus spending"

Posted by ben whittaker
on 6/28/2012 5:09 PM

couldn't agree more. I think we all know who to vote for--or rather who to vote OUT in November!
#MittRomney

Posted by Christina Willmann -> BFS\BG
on 6/29/2012 12:19 AM

Couldn't agree less. Great day for people in need of help!

Posted by Jeroen Van Zwol -> ?FW\<N
on 6/29/2012 10:55 AM

Yet another attack on our rights as states and individuals. Socialism is coming strong. Yes we know who to vote OUT!

Posted by Paul Mavrakos
on 6/29/2012 12:20 PM

I also agree, that the progressive movements to remove our rights, one by one, and moving toward a socialist society, is the decay of what this country was built on. Beginning with the lack of support for competitiveness in our schools, and our children, "everyone is a winner and there are no losers." This type of thinking is non-productive, at best. We will all now have the opportunity to pay larger deductibles in our insurance.

Posted by Roberto Gutierrez
on 6/29/2012 1:04 PM

Another tax and increase cost for health care..that is what you get besides USA bankrupt and your increased taxes again!!!!!
.DON'T ARGUE WITH ME UNLESS YOU HAVE READ AND REALLY KNOW WHAT OBAMACARE IS ABOUT..I KNOW I HAVE DONE MY RESEARCH NOT JUST LISTENED TO THE NEWS
Today’s ruling on ObamaCare is simply surreal. The Obama Administration sold the individual mandate again and again with the argument that it was not a tax. Then they argued before the Supreme Court that it was a tax, because that was the only way to defend it constitutionally.
Justices Scalia, Thomas, Kennedy and Alito clearly saw through this exercise in semantics, and they deserve our thanks for their commitment to the Constitution and the law in their dissent. The best that can be said for Chief Justice Roberts, in voting to uphold the law, is that he rejected the administration’s argument that the mandate was permitted by the commerce clause.
That said, it should never have been the job of the Supreme Court to clean up a terrible piece of legislation perpetrated by Congress and the White House. ObamaCare may have been declared constitutional by five justices – although not in the manner the White House sold it, which is telling – but that doesn’t change the fact that it is a horrible law that will bankrupt this country, explode health care costs and diminish the quality of care throughout this nation.
Government tyranny has been slowed, but not stopped.
What today’s ruling means is that anything government can call a tax, it has the power to do. Regardless of the semantics, we are subjected to government tyranny.
This merely emboldens the government to keep taxing and taxing and taxing.
Today is a temporary setback. The American people have hated ObamaCare since its inception, and they can see that it is already driving up health care costs. The ruling that really matters will come on November 6, when We the People have the opportunity to replace the president and the Congress who created this monstrosity with new leaders who will replace it with measures that value market forces and free choice.

Posted by Francine summers
on 6/29/2012 4:40 PM

No argument with Mr. Rockar's restatement of APTA member's committment to patients and quality of care, but what makes him think that ObamaCare is going to accomplish our goals? The new law's goal is first to over-regulate and reduce reimbursement to providers without regard to their viability. Quality of care is always impacted negatively in that kind of environment. It then becomes survival of the....hum.

Posted by Elizabeth Perez
on 6/29/2012 5:21 PM

Finally the United States joins the majority of developed countries and recognizes that access to quality health care is a right for all citizens. This hardly represents a march to socialism or a loss of individual freedoms. You have been paying for the uninsured for some time with increased premiums for their unpaid bills. The overall health of this country will increase and lord knows it's about time we see our infant mortality rates move up from the bottom of the pack. The mandate is necessary to avoid people buying insurance "on the way to the hospital", given the other provisions that disallow exclusions. Woman can celebrate no longer being charged higher premiums than men of the same age. Preventative care will now be available to all, and I think we all agree this improves overall health and decreases the "disease management" focus of our current system. I anticipate the elimination of arbitrary preferred provider contracts that are nothing more than insurance companies holding providers of health care hostage for decreased reimbursement rates. Health care will still be privately administered and health insurance will be still in the hands of private industry...a far cry from socialism. The breaking down of state barriers for purchasing competitive and affordable insurance coverage is an ideal example of our beloved capitalism. Let these companies compete for the 40 million people about to join the ranks of the insured. Keep in mind by the way....the "tax" for not buying insurance is optional...you can avoid it by BUYING INSURANCE!

Posted by Julie Warren
on 6/29/2012 6:24 PM

Truly one of the darkest days in our county's history. This has nothing to do with "helping people", it is about CONTROLLING people by governmental intrusion into our most personal and intimate choice: our health. Once the government regulates your health, it's control over you is complete. This is tyranny. Notice the elites IN government who voted for Obamacare EXEMPTED themselves; it is for us "little people" to endure. WE will suffer through outrageous insurance premiums and decreased quality/ availability of care (i.e. - rationing, which is inevitable) My husband an I pay for our own insurance - it has risen $6500.00 since Obamacare was passed. Obama promised that nobody's rates would increase; we have had to take worse and worse coverage in order to afford it. Of course rates must increase if the insurance companies are forced to cover everyone with pre-existing conditions. People will just pay the $2,000.00 a year fine... oops, "TAX"..., then slam themselves into an insurance policy when they have a serious problem - like insuring your house after it has burned to the ground. They will save tens of thousands every year by scamming the system - and the rest of us idiots are left holding the bill. If you are foolish enough to think that government run healthcare is the way to go (which this is leading to by design - surely private insurance will self destruct because of the mandatory inclusion clause), as with EVERY gigantic, inefficient government bureocracy, there will be plenty of waste, fraud and abuse. Just look at Social Security and Medicare, both of which are on the brink of bankruptcy. And how is Medicare going to fare when Obama pulls $500 billion out of it (part of the law) to pay for his signature Ponzi scheme? That's right - the seniors can "just go take a pain pill" like he said - if they aren't healthy enough to work, they can just go home, suffer and DIE. Like in any Marxist nation. Now just how is THAT doing what's best for our patients??????

Posted by Marilyn Jones, PT, DPT, MS
on 6/29/2012 7:14 PM

Increasing the DEMAND in an industry that already has a shortage of SUPPLY will DECREASE cost? Typical logic from a politician. This law is just further proof that all the previous attempts by the federal government to intervene in the health care industry were a complete failure in regards to the economics of it all. This is a short term gratification for people who think this is a "win", but long term, consider the provider-patient relationship destroyed. If people thought the insurance companies had too much power before and getting in the way of Tx, well this law just increased their power and decreased the autonomy between provider-patient.

Posted by Josh
on 6/29/2012 7:53 PM

I think the salient points are here made. I must admit that I have for some time wondered just what most of my colleagues really think about this issue. I know what I think. It is refreshing, at least, to see a clear majority here speaking out against this monstrosity. For those who now think that socialism is a good idea: You never really know it until you are living it. Remember, it is the "progressive" socio-fascists who will be the ones who really push grandma's wheelchair over the cliff.

Posted by John
on 6/30/2012 12:38 AM

How can APTA stay "neutral" with this Supreme Court ruling?! As I can see from prior comments, majority of us understands that the quality of care will go down dramatically simply because the same monetary funds will have to be distrbuted among much larder number of consumers. We already know that Medicare will suffer 30% decrease in payment to providers, although even with the present $1880 yearly cap many of our elrerly patients are left undertreated or have to pay out-of-packet for their PT. Where will we find the $$ for a preventative care if we don't have them now with the excisting system? Really, some people live in a dream world! Market don't lie: all insurance companies actions went down today, one day after Supreme Court ruling.. How, do you think, insurances will react? Of course, the premiums will go up even higher.
I came from the country where medical care was free and available for everybody. I came from former Soviet Union, so I know first hand what

Posted by bella kavalerchik
on 6/30/2012 1:01 AM

To see the comments made by our members and to hear that the APTA is "neutral" on the position of the Affordable Care Act is to demonstrate how far away we have come from deserving to call ourselves a profession. A health profession has an ethical duty to serve society not to make profits for ourselves.
The ACA is a national necessity. The APTA needs to inform its members on why access to affordable care would actually benefit physical therapist; not because of our need to get paid but because society needs physical therapists to return people to health. It is not about access to a physical therapist so your private practice can be more profitable; it is about creating access for a child or adult who needs physical therapy for their health.
Our society does not need more orthopedic specialists in physical therapy who will only see healthy people between 14-50 years old with a joint problem. That is actually a very small proportion of what all physical therapists actually do. What we need are primary care physical therapists who know something about physical function across the life course. We need to protect the health of the population from falls whether that is a teen off a skate board or an elder in their home; we need to know that a family who has a 4 year old that does not speak is most likely a child with autism; we need to be able to recognize the gait pattern and average gait speed of a healthy elder from the shuffling gait of someone with Parkinson's disease.
We should hang our head in shame if we do not understand that lack of access to affordable health care for all is what has driven our healthcare costs up. If you are under 65, working and insured, you are lucky...30% of working adults under 65 are uninsured. If they get whip lash or hurt their back are you going to see them? The answer is NO...unless they pay you cash. Think about that...we are no better than other professionals who separate the haves from the have nots. When was the last time you saw a person in a wheelchair? Remember who those professionals were? They were physical therapists who took care of the poor and disabled along with people who ran again after our treatments.
President Rocker, please bring our profession back to its roots. We have lost our moral compass. We are not the Association of happy, jumping people that you see on the Foundation for PT and the APTA website. We are the American PHYSICAL THERAPY Association. We have a professional obligation to speak up for all people with disability. Some have episodic health issues like LBP, others are born with congenital deformity or developmental motor dysfunction; some are permanently injured and will never recover full function. We are the profession responsible for all of them. Support Obama care, it will be good for people who need a physical therapist and do not get to see one.

Posted by Katherine J Sullivan
on 6/30/2012 3:30 AM

Thank you Ms. Sullivan, I find your comments grounded and agree with your train of thought. The most heartbreaking times in my career are when patients come in my office seeking care they can not afford, insured or not! They always choose to go without. I wonder how many of our peers understand the true cost of that in the big picture of healthcare?

Posted by Dana
on 6/30/2012 11:37 AM

All you raging against this, especially you, Francine Summers, you need to really understand what this law is about.
These are the United States. And to make it a more perfect Union, we can't let people walk around with tumors because no one would insure them. We can't have little ones born with pre-existing conditions that either will never get covered, or will get stuck with year end limits and life term limits. 22 year olds that might be diabetic that cannot be covered under their parents or not denied coverage altogether. Live like them for once and then say the selfish things. What freedom are you losing here?
The only Developed country in the world that turns health care into a profit model will remain the same. Nothing has changed, no freedom have been impinged or taken away contrary to blowhards on FOX News or any other Tea Partier. This is the same version that Republicans supported whole heartedly, once, but now that it comes from Democrats and Obama, it is all bad. Yeah, that is how the game is played. But many of you know this is about personal responsibility and accountability. I do not want to pay for the folks who walks into an ER with no insurance and expect to be treated. I want them to do the right thing and buy insurance.
Small Businesses (under 50 employees) are not mandated under PPACA. No change for them. If they chose to provide it though, they will get tax breaks. Actually all businesses will get tax breaks.
And lets swat down the lie about high taxes already. What Justice Roberts said was, the penalty should be more of a tax rather than a mandate. That's it. You can buy the insurance to prevent a small fine when you are filing your taxes, and if you cannot afford it, you will be provided subsidies.
The tax penalty is required to have everyone join the plan, since without everyone joining, the private insurance companies cannot operate for a decent (not vulgar) profit. From CBO estimates, only around 1% of the population would ever come to paying the tax penalty.
Close to 40 Million Americans will benefit from this. The rest of you will enjoy the benefits when you get sick as well.
Educate yourself with the actual facts from Healthcare.gov, and not from ridiculous talking heads on TV and radio.

Posted by P T Barnum
on 6/30/2012 12:10 PM

I appreciate all the insightful comments made by so many well informed professionals. I appreciate the education and actually have not read the ACA document. I know some of the implications but realize there may be much imbedded in the document that may be very controversial as well as upsetting to us (citizens). To put in a comment from a small Ma practice. We have legislated mandatory healthcare in Ma. I for one know because I have a number of patients come to me for therapy that cannot receive care otherwise as their insurance is not accepted by another practice or hospital. I am talking Mass Health, Neighborhood health, Network Health and some of the other insurances that were created to allow for Ma residents to obtain coverage. I am personally appalled that so few practices/hospital organizations accept these insurances. I applied to be a provider as soon as I was aware that these plans were in place. I hope that the changes coming will be positive for both the provider and the patient. What I most hope is that all providers will willing obtain contracts with these entities as the program is put into place. I think change is good and we are most definitely in need of change. Sorry that it has to be so drastic but you cannot say that you were not warned or aware something like this was coming and we do need to start somewhere. So it has been done. I know that there are many practices that will be affected myself included. As the prior commenter addresses there is a need for a comprehensive plan that allows so many that could not afford insurance to become insured. I have seen it work for many of the folks in my very small area. I see people coming in for therapy that had Mass not taken the stance it has and mandated insurance would not be able to obtain the care that they need. I am a PT just a small branch of the medical profession as a total entity. I am guessing that these very same folks I am speaking of are able to obtain coverage for their children or themselves for a vast array of potential medical issues that otherwise might not be available to them. The above comments are my opinion only. Thank-you

Posted by Kaethe Flynn
on 6/30/2012 2:06 PM

I think its awesome for the most part. This is America people! We should be making healthcare available to
ALL Americans! More people will be eligible for Medicaid services & only those that can afford to but their own insurance will be required to do so & they SHOULD. Everyone has to have car insurance so why not health insurance. Guarantee the nay- Sayers don't really have a clue how thus also helps insure they everyone has access to Physical therapy (now a requirement of every plan). Quit politicizing the issue, & get informed! The funny thing is that Mass did the same thing basically, and is providing 98% of their residents with healthcare,...where was the screaming then?!?

Posted by KHartsell
on 6/30/2012 7:04 PM

Amen to the comments that support the bill. It's not perfect, but it's something when nothing was getting done. Medicare, I believe, has a longer 1/2 life I only hope that the necessity of the law is reviewed periodically until commercial health insurance is back on it's feet. Wake up people, people have not been buying health insurance or buying plans that offer the cheapest premium and commercial insurance companies don't have the money you all think they do, that's the fundemental reason why the feds need to get involved. Like K Flynn, I own and operate a 6 therapist location in a state that has already expanded their medicaid back in 2002 and again in 2009. The plans work! I feel so good that I can treat a Mrs. Gomez for a lumbar radic for 5-8 sessions that has been keeping her from working > 20 hrs a week in an area of need and be reimbursed > than any in-network commercial plan that exists in my state. My peers who have set up offices in more wealthy neighborhoods work out of network, treating someone with fibromyalgia 50 times a year because their out of network commercial plan favors benefits for those that pay for higher premiums. And my peers that call themselves health care providers set up rediculous out of network fees on superbills. Sickening! The new law is NOT socialism. It's initial competition to the commercial insurance programs to get people to invest in healtcare vs. a $300 cell phone. For those who have seen their premiums increase, its for a short term, because they will have to eventually compete for in-network health care providers when they have the money to do so.

Posted by David Bullock -> >LU`CH
on 7/1/2012 1:39 PM

Reading some of these comments makes me very sad to be part of a health profession that has been hijacked by the pursuit of the almighty dollar. You people make me question my faith in humanity. Many of you sound just like the doomsayers back when Medicare first started, Boy you would have thought this country was dead back then, but no, it has continued to grow and be the powerful nation that it is. It did not turn into a socialist country when Medicare started like all the bozos claimed. It became stronger and more respected. This law drags the U.S. into the 21st century, kicking and screaming. Like PT Barnum said a few comments ago, educate yourself, for real, not just from the talking heads like Francine Summers has done thinking she can call that research. Then maybe you can speak of actual realities and not some fear-mongering inanities and conjectures. All of these opposing arguments are so old and based on so much bias and fabricated, made-up, potential scenarios, not anything based on reality.

Posted by Joel Anderson -> AGVbDG
on 7/1/2012 4:15 PM

As a PT and an ethicist, I see health care reform as society deciding if health care should be a social program or a business industry. Most people have a bias to one way or the other. Currently, health care is straddling the line. I expect it will continue this pattern. How? is the question. As a person who is politically independent and philosophically moderate, I know that this is not the end of health care reform. Future Congresses and Presidents will make many changes - some I may agree with and some not. I also know that respectful public discourse will move us forward more as a profession and as a society than most of what has been written in this comment section.

Posted by Debra Gorman-Badar
on 7/1/2012 6:29 PM

All though not perfect, something needed to be done. It seems like the APTA focuses a lot on Outpatient services, however the Acute Care and Rehabilitation areas have been suffering because of the large numbers on uninsured. Some progress towards improved quality for at risk populations is likely to come out of this.

Posted by Brent Perdrizet
on 7/1/2012 9:43 PM

Why does everybody hate this law so much? As a small private practice owner, in the last year it has affected me by giving me more insured patients and my 20 year old son coverage. Yes, my insurance premiums rose, by 8 percent, but they rose by 8 percent last year and the year before, the same amount that they were going to anyway, just like they do every year. And my husband, who has diabetes and thyroid cancer, continues to have coverage. Oh and the insurance company that I use to provide me and my employees health benefits wrote me a letter saying that they were going to do their best to use 80 percent of my premiums for health care but in the event that they could not I would have to be prepared to figure out how I would issue a refund to my myself and my employees. What is the problem?

Posted by S Foxx
on 7/2/2012 12:17 PM

Thank you to Katherine J Sullivan (above) for a great post! I agree with her philosophy.
I'm also dismayed by the negative tone I see and hear from so many of my APTA peers who seem to "hate" the ACA because of who passed it and how it was passed.
I'm sorry to see how politics have invaded the professional space physical therapists inhabit.
I'm currently living in Spain and running a cash-based physical therapy practice.
I've started small but I have a healthy, double-digit growth rate. I charge €25 per 45 minutes (about $42). If you think that's too low remember that Spain has 50% unemployment in the young and 28% unemployment overall.
Also, people can go a get a "fisio" for "free" (covered under government social security) - but they elect to see me via direct access.
They've "opted-up" to a higher level of service using the "free market" in place of the Spanish social security.
Basic Spanish healthcare is fully covered. Their medications are free, basic screening, immunizations, family doctor visits and emergency room visits are fully covered.
In short, Spanish citizens (and tax-paying business owners like me) have some semblance of what the ACA purports to deliver to Americans.
I think the challenge, going forward, is to deliver these basic services to Americans without becoming financially insolvent, like Spain.
People like Francine Summers, who post IN ALL CAPITAL LETTERS to make their point, fail to remember that American innovation has delivered two centuries of surprising and wonderful change that have put America on top of the world's cultural, economic and scientific scale.
I am optimistic that the the Supreme Court's decision on the ACA is just the beginning of another wonderful round of American innovation that will amaze the world.
Tim Richardson, PT
http://www.PhysicalTherapyDiagnosis.com

Posted by Tim Richardson
on 7/2/2012 4:42 PM

While I agree that every American should have health care coverage and feel confident that they have somewhere to turn in the event they have a serious condition requiring medical attention, I am concerned about a few items in the ACA. One, that, as previously stated above, a person can essentially remain uninsured until a situation arises that require them to obtain health insurance then purchase a plan due to the fact that pre-existing conditions cannot be denied and have the insurance company pay for any services they require then drop the plan when everything has been paid. If you don't think this will affect all of our premiums then you don't understand the insurance industry's business. Second, while I am aware that the Obama plan will entitle all Americans to be covered, there is to be an "Administrative Board" that will make decisions on the care of individuals over a certain age. In order to save $$ I am concerned that there is an incentive to cut costs by denying or delaying care to these individuals (much like the current Workers Comp plans). Third, if the cost of operating a private practice rises and reimbursements diminish the logical next step is to reduce the budget by either laying off staff or cutting every therapist's pay. While many of the therapist above mentioned the idealism of providing care to ALL Americans regardless of the amount of reimbursement, they need to remember that (while we need to place the care of our patients over the potential for business profits) healthcare is a business and requires profits to remain in existence as well as to pay the ever rising demand for salaries and benefits by the PT's the private practices employ. Additionally, if anyone has ever started their own private practice they can appreciate the costs and (financial) STRESSES involved in opening and operating their own business in an ever changing economy and insurance market. For that alone ample remuneration should be expected. However, as a private practice owner myself I always have (and have often exercised) the option to waive or reduce payments for those that truly cannot afford to pay however this option may be diminished if my bottom line no longer permits me to be selectively magnanimous to those we feel are deserving. Additionally, I struggle with the fact that this will be another avenue for the certain lazy individuals that we occasionally see in our practices and our communities that have no desire to find work and welcomes the opportunity to enjoy yet another benefit afforded them by our tax-paying citizens while continuing to live off the system. If anyone read the Supreme Court decision and rationale, there is absolutely NO PENALTY that will be enforced if you do not pay the "tax" (penalty) for not carrying insurance coverage.
In closing, it is my hope and prayer that the ACA will turn out to be a good plan for all Americans but from the highlights and articles I have read and the observations I have made when the government becomes involved in any system, I have my doubts.

Posted by Randy Veroline -> =KS\=I
on 7/4/2012 12:34 AM

I think we have to realize that this bill is a decision at a point in time. I for one wholeheartedly support the direction this bill takes us. I am sure though that there are aspects of it that will need tweaking as we get into it. So did Medicare and Medicaid. As a profession it will allow us to see more individuals and provide the same care we can provide to those who have not only insurance, but insurance that is of a type that we can financially accept. We will have to make changes perhaps in our business structures in many areas of practice, including facility based practice in order to meet the needs of society...and that is what we are here for, to meet the needs of society. they give us the right to treat them. It is a privilege we have to earn every day. There are many "rights" that we enjoy as americans, but each of them comes with a responsibility we have to meet. I for one feel this helps me as a practitioner meet the privilege society has given me to take care of them

Posted by Jim Dunleavy PT MS
on 7/7/2012 12:03 PM

The healthcare law is a JOKE, Obama is a JOKE, and the APTA is a joke because they cannot accomplish anything positive for our field. We waste all of our money with membership dues because as far as I can recall over the past 5 years there has not been one change in favor of Physical Therapy.

Posted by Tony
on 7/7/2012 1:51 PM

Medicare, Obamacare, third party payer, it is all the same....good job (therapy), or bad job, SAME PRICE, until we have a cost/cash based system the reimbursement will be the same regardless of who provides the therapy, experienced therapist with name recognition and track record or new grad PT/PTA with no experience. People say health care is too expensive, meanwhile they get home loans for hundreds of thousands of dollars....there is no reason healthcare and Physical therapy cannot be financed the same way as major purchases like homes or cars..........supply and demand may create a market for those so called one percenters seeking physical therapy to find those of us who can get the job done without all the paperwork......GOD BLESS (AND SAVE) AMERICA.

Posted by Paul
on 7/11/2012 11:48 PM

THOSE WHO TREAT THE PATIENT THROUGH USING HOMIOPATHY ARE DOCTOR BECAUSE THEY TREAT THE PATIENT THOSE WHO ACCEPT THE WAY OF AURVEDIC THEY ARE ALSO DOCTOR THUS THE PHYSIOTHERAPIST TREAT THE PATIENE BY THERE WAY SO WHY NOT THEY USE PREFIX AND WHY THEY HAVE NO GOVERNMENT POST?WHY IT IS A PARAMEDICAL COURSE?